Staffing, personnel, and trainingType B
- Official classification
- Type B
- Official code
- 87411(f)
- Regulation authority
- CCR
What the official deficiency says
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties. This requirement is not met as evidenced by: Deficient Practice Statement Based on records reviewed , the licensee did not comply with the section cited above in 1 out of 3 employee as Staff 1 did not have a health screening on record. This poses a potential health and safety risk to persons in care.
Official plan of correction
POC Due Date: 10/29/2025 Plan of Correction Faciltiy agreed to obtain a health screeining LIC 501 and provide proof to LPA by POC due date.
Fire safety and emergency preparednessType B
- Official classification
- Type B
- Official code
- 1569.695(c)
- Regulation authority
- HSC
What the official deficiency says
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and record review, the licensee did not comply with the cited above as there is no documentation of emergency drills. This poses a potential risks to persons in care.
Official plan of correction
POC Due Date: 10/29/2025 Plan of Correction Facility to conduct emergency drill and provide proof to LPA by POC due date.
Staffing, personnel, and trainingType B
- Official classification
- Type B
- Official code
- 1569.625(b)(2)
- Regulation authority
- HSC
What the official deficiency says
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training. This requirement is not met as evidenced by: Deficient Practice Statement Based on records reviewed the licensee did not comply with the cited above in 2 out of 2 employees as there are not training records on file. This poses a potential risk to health and safety to persons in care.
Official plan of correction
POC Due Date: 10/31/2025 Plan of Correction Facility agrees to conduct training and provide proof to LPA by POC due date.
Health conditions and treatmentsType A
- Official classification
- Type A
- Official code
- 87608(a)(3)
- Regulation authority
- CCR
What the official deficiency says
(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions.(3) A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order. This requirement is not met as evidenced by: Deficient Practice Statement Based on observations and records reviewed the licensee did not comply with the cited above in 6 out of 6 residents as no rail orders were on file for residents. This poses an immediate health and safety risks to persons in care.
Official plan of correction
POC Due Date: 10/29/2025 Plan of Correction Faciltiy removed rails from all residents beds and will obtain physician orders for half rails only and provide proof to LPA by POC due date.
Fire safety and emergency preparednessType A
- Official classification
- Type A
- Official code
- 87203
- Regulation authority
- CCR
What the official deficiency says
All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation the licensee did not comply with the cited above in 3 out of 4 bedrooms as the smoke detectors were not operational. This poses an immediate health and safety risk to persons in care.
Official plan of correction
POC Due Date: 10/22/2025 Plan of Correction Facility agreed to replace all non operational smoke detectors and provide proof to LPA by POC due date.